South African women who seek goods and services from sexual partners more likely to become HIV positive within two years

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Young South African women who
engage in sex or have relationships partially motivated by economic gain are more likely to become
infected with HIV, Rachel Jewkes and colleagues report in the Journal of AIDS & Clinical Research.
These data add to previous findings from this cohort showing that women who had
a violent partner or who were relatively powerless in a relationship were more
likely subsequently to acquire HIV.

The authors therefore argue that HIV prevention programmes
need to find ways to help young women to avoid gender inequity, violence and
transactional relationships. Moreover, background research they have conducted with
men and women sheds light on women’s and men’s expectations in relationships.

Relationships and HIV infection

In order to clarify the links between gender issues and HIV
infection, Rachel Jewkes of the South African Medical Research Council examined
data from the cohort of young women recruited to evaluate the impact of a
behavioural intervention known as Stepping Stones.
Women from both the intervention and control groups are included in this
analysis, as long as they were HIV negative at the beginning of the study, had sex
whilst in the cohort and completed follow-up after 12 and 24 months.

The researchers examined the behaviour and experiences that
the women reported at the beginning of the study and whether they subsequently acquired HIV. The study
design is therefore more robust than a one-off cross-sectional survey, as it
can suggest whether a link between one factor and HIV infection is causal or
not.

Included in the analysis are 1077 women aged 15 to 26 years,
with an average age of 18 at baseline (the beginning of the study). The
majority were very poor, still in school, unmarried and already sexually active.
The cohort was recruited in primarily rural parts of the Eastern Cape province.

During the two years of follow-up, 127 women acquired HIV.
In other words, the incidence of new infections was extremely high, but not
unusual in this setting, at 6.2% a year.

Data from this cohort, published
two years ago in The Lancet,
showed that women who reported having relatively little power in sexual
relationships at baseline (for example, feeling obliged to sleep over when a
boyfriend wanted her to) were more likely to subsequently acquire HIV. In women
with medium or high relationship power equity, incidence was 5.5% a year; in
those with low relationship power equity, it was 8.5% a year.

Similarly, women who reported at baseline that sexual
partners had been either physically or sexually violent were also more likely
to go on to acquire HIV. Women reporting either one or no incidents of intimate
partner violence had an incidence of 5.2% a year, but women reporting two or
more incidents had an HIV incidence of 9.6% a year.

Both these differences in incidence were statistically
significant after adjustment for confounding factors.

Rachel Jewkes suggests that certain ideals of masculinity
which are widely accepted in some South African communities legitimise unequal and often violent
relationships. Men are expected to dominate and control women, and violence may
be justified to enforce and demonstrate this. This may place women at increased
risk of HIV infection by creating psychological distress, encouraging women to
be more acquiescent, preventing women from influencing the circumstances of sex
(including condom use and the frequency of sex) and allowing men to have
multiple and concurrent partners (and therefore more likely to themselves have
HIV and sexually transmitted infections).

In their new study, the researchers turn to the issue of
‘transactional’ sex – in other words, when a woman reported that part of her
motivation for having a sexual relationship was that she expected her partner
to provide cash, food, cosmetics, clothes, transport, a bed for the night or to
do some handyman work. These relationships are seen in terms of men fulfilling
a traditional provider role, rather than as being akin to prostitution.

Transactional sex was asked about, at the beginning of the
study, in relation to different types of partners. A total of 143 women
reported it in relation to main partners, 59 women reported it with ongoing and
usually secret second partners (known as makhwapheni
in the Zulu and Xhosa languages), and seven women reported it with one-off
partners.

In relation to main partners, there were no statistically
significant differences in HIV incidence between those women reporting and not
reporting transactional relationships.

However, when looking at makhwapheni
and one-off partners, women who did not report transactional relationships
had an HIV incidence of 5.7% a year, but women who did have a transactional
relationship had an incidence of 14.5% a year.

The researchers then adjusted their figures for other
factors which are known to influence HIV incidence (including condom use, age, herpes
infection, relationship inequity and intimate partner violence). They
calculated that having transactional relationships with makhwapheni or one-off partners doubled the risk of acquiring HIV
(incident rate ratio 2.06, 95% confidence interval 1.22 – 3.48).

Although it could be hypothesised that transactional
relationships are risky because male partners are more likely to be older (for
example a ‘sugar daddy’) or because they are associated with women having more
sexual partners, neither of these factors were associated with statistically
significant increases in the risk of HIV infection.

The authors suggest financial and material vulnerabilities
may introduce a particular type of vulnerability into sexual relations. “When
there is an absence of explicit negotiation and a bolstered sense of male
entitlement, men perceive that gifts of cash result in a woman accepting sex on
his terms, which are often without condoms and without space to assert
preferences for monogamy and so forth.”

These highlighted the range of qualities women were looking
for in a partner. Some women expected to be provided for:

“I wish I would have a
relationship with someone who would only be in love with me, he should not
drink and smoke, or I want a person who loves me who will always think about me
and I will think about him. I don’t like someone who has multiple partners. I
wish I should just have a person whom I know that I am in love with, but I wish
he should give me money when there is something that I need. I would see that
this person does not love me if he gives me nothing, but he sees that I am
suffering, no I could see that he does not love me… I wish he should not spend
a long time without seeing me and if there is something I need from him knowing
that he has it, he should give it to me.”

For many of the participants, obtaining and keeping
boyfriends was a central pursuit. Some women were proud of what they had been
given, as it reflected their own desirability as well as their boyfriends’
prosperity and status. But many desperately needed the items and money they
received, although it was often inadequate for their needs. This teenager was
bringing up the child she had had with a married man.

“He gives me the amount he thinks is good for
me, but he never gave me an amount of R200 (US$28). It is usually less than
that amount”.

When dating, women had considerable agency and took care in
choosing a partner they felt able to submit to. But once relationships were underway, agency was usually lost – most tolerated their partners’ violent and
controlling behaviour, and were publicly obedient and respectful. The
researchers consider that women often accepted a surrender of power in order to
be respected as ‘good’ women and partners.

But there was diversity in women’s views and experiences –
some women living in bigger towns presented themselves as being ‘modern’ and in
control of their lives, although the researchers comment that this was “part
reality, part fantasy”. Others, especially those who had gone through the
Stepping Stones intervention, expressed a desire for mutual respect and
autonomy, and said they would not accept violence and controlling behaviour.

And what about men’s perspectives? Jewkes reports that a
substantial proportion of South African men think that they are expected to
provide for their partner and that they wouldn’t be able to have the
relationship if they didn’t fulfil that provider role. These social
expectations can put a pressure on men which may be resented by those who are
unemployed or underpaid.

Data
from a household survey conducted with a randomly selected sample of 1645
men in the Eastern Cape and Kwa-Zulu Natal provinces sheds light on the issue.
Half the men were under 25 years, nearly half were unemployed, 85% were Black
African and a third were married or cohabiting.

Two thirds of men reported relationships where they
perceived that their partner had got involved in the expectation of receiving
goods and services. This was reported for all types of partners and men tended
to give similar items (cash, food, clothes, cosmetics, accommodation, etc.) to
main partners, makhwapheni (secret
secondary partners) and one-off partners. Prevalence was high across a range of
social and demographic groups.

The proportion of men reporting transactional relationships
was much higher than in the cohort of Stepping Stones women. This may be
because perceptions of what relationships are about can be different or because
men want to present themselves as being able to provide.

In contrast to transactional relationships, fewer than
one-in-five men reported sex with a prostitute, and there was relatively little
overlap between the two. These are seen as very different behaviours and
prostitution is stigmatised.

But the
same data set showed associations between men’s involvement in
transactional relationships and self-report of perpetrating rape, intimate
partner violence and various other forms of criminality.

Moreover, participants answered questions about their
attitudes to women and relationships, which suggested that men involved in transactional
relationships tend to have socially conservative and hostile attitudes towards
women as well as an idea of sexual entitlement.

HIV prevention interventions

Rachel Jewkes and colleagues conclude with the implications
of their research for HIV prevention. “Young women are very vulnerable and much
less able to influence their own sexual risk than men of the same age,” they
write. “These findings provide support for those who are investigating
interventions to enable young women to avoid transactional sex.”

Moreover: “Women need to be supported and brought to a tangible
understanding of the possibilities and potential for them to assert control in
sexual and relationship domains of their lives. In this respect, both skills
building (communication and other skills) and tangible economic empowerment are
important.”

Similarly work with men should focus on “reconfiguring how they
see themselves as men.”

References

Jewkes R et al. Transactional Sex and HIV Incidence in a Cohort of Young Women in the Stepping Stones Trial. Journal of AIDS & Clinical Research 3:158, 2012. (Click here for free full text)

Jewkes R et al. Sexuality and the limits of agency among South African teenage women: theorising femininities and their connections to HIV risk practices. Social Science and Medicine74:1729-37, 2012. (Click here for free abstract)

Jewkes R et al. Transactional relationships and sex with a woman in prostitution: prevalence and patterns in a representative sample of South African men. BMC Public Health 12:325, 2012. (Click here for free full text)

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